Depression, like most mental illness, is a complex and variable condition. It can present, as Denis’s did, with fatigue and excessive sleep, but also with inability to sleep—insomnia and/or frequent waking through the night. Some people feel sad and discouraged, some feel nothing at all or empty, and others feel irritable and anxious. Some cry a lot, others feel they want to but cannot. Other common symptoms include apathy, lack of motivation, not caring, low self-esteem, feeling like a failure, loss of pleasure, and feelings of guilt, worthlessness, hopelessness and helplessness. There are also physical symptoms such as fatigue, loss of appetite, and difficulty with focus and concentration, unable to make decisions. Some people have almost all the symptoms, others only some.

Some people feel so bad they reach the point of suicide, and it is important, as Denis noted, to always ask about this dark potentiality; (surprisingly, people are seldom offended by this question). Sometimes depression can be worse for Christians because of added guilt, perhaps feeling like God is punishing them, and the expectation that they should be full of joy. Because of this, it is essential that all Christians, leaders especially, be educated about depression and suggest to suffering family and friends that they seek professional help (both physicians and psychologists can diagnose and treat depression, but only physicians can prescribe medication).

The exact cause of depression is unknown. The origin is best described as multifactorial—there are genetic, personality, psychological (like stress, unresolved grief, past trauma that has not been dealt with), spiritual, and biological factors (like hormones, medication side effects, chronic illness, lack of daylight, neurochemical deficiencies). Although many psychiatrists focus only on the neurochemical aspect of depression, the truth is we do not know which comes first: the psychological factors may cause the neurochemical imbalance. Usually, the cause is a combination of many factors, although in some people, biological factors appear stronger, and in some, psychological factors are more prominent. Sometimes depression “just happens.”

Some Christians think that sin (especially if unrepentant) causes depression, but, although it may be a factor in depression, there is no biblical evidence that this is the case, and we all know “sinners” who do not suffer depression. Some Christians blame evil spirits for depression—again, I would argue that they may be an influence, but are not likely to be the sole factor. The important thing is to recognize that there are many aspects to depression and, if we focus only on one, then we may miss other important factors in our treatment.

The Bible does not mention depression, although the writers of Lamentations, Ecclesiastes and many of the Psalms appear quite depressed! Understanding the relationship between God and nature can help us understand depression. The Bible is not a medical or psychological textbook, but does encourage us to be responsible in understanding God’s creation. Because we live in a fallen world, there is much wrong with creation, depression being perhaps one example. Understanding suffering is a complex topic and there is a mysterious element to it, evident in God’s questions to Job (e.g., “Where were you when I laid the foundations of the earth?”). Furthermore, if we truly cared for creation and each other in the manner God intended, perhaps there would be less suffering in this world. I do not believe God wants us to suffer, although God will certainly use things like depression to guide us into spiritual maturity. Christian mystics, such as John of the Cross, refer to the “dark night of the soul” (I suspect that many of these writers had undiagnosed depression) as something God uses to teach us. Their writing has helped many people, but again I would caution against viewing divine intervention as the only factor in depression. We need to question if there is a lesson to be learned; however, this does not mean there always is. Sometimes it just happens.

Considering the multiple factors in depression can guard against simplistic views, such as attributing depression solely to God, sin, the devil, or chemical imbalances. If we tell people that their sin is the reason for their suffering, this will make people who already feel bad feel worse, and may result in them being deprived of valuable medical treatment. Christians do not need to choose between the Bible and medication: Dealing with depression can be a “both/and” rather than an “either/or.” Conversely, if we tell people that they have a “simple” chemical imbalance, they will be deprived of the opportunity for psychological and spiritual healing. I’ve had more than one patient who came to me with a diagnosis of depression, but I subsequently discovered a history of childhood abuse which had not been addressed. Some patients were able to stop their medication once they received appropriate counseling.

Because there are many aspects to depression, treatment needs to address all of them. I have heard Christians claim that all they need is the Bible, but therapy never consists of “just the Bible” or “just medication.” Denis admitted that he needed medication, but also that his “brain needed a break.” (I would add that for most people, their body, mind and spirit also need a break.) There were biological and psychological aspects to his depression. I tend to approach the treatment of depression using the “three Ps” (four for Christians): practical, psychological, pharmaceutical, and prayer (not in any particular order and usually combined).

If severe, the first step is education and medication. For example, when someone can barely get out of bed, they will be unable to exercise. If someone cannot concentrate, they will be unable to participate in prayer or counseling. Practical treatments include things like rest (as Denis wrote, and as the Sabbath command advises), reducing stress, regular exercise (even a brisk walk around the block helps), good nutrition (food and mood are related), vitamin D (especially in the winter in northern climates), and keeping a regular schedule (e.g., going to bed at the same time each night). At the psychological level, counseling can help people determine if they have unresolved past issues (e.g., childhood abuse, repressed grief), as well as educating them about the relationship between thinking and mood, and adjusting thoughts as needed (this is known as cognitive behavioral therapy and helps patients to get proper perspective on life events). Finally, in terms of pharmaceuticals, there are many medications that increase serotonin and/or norepinephrine and/dopamine levels in the brain, thereby alleviating the symptoms of depression. Response can vary and some people need more than one medication. The typical treatment period is six to twelve months but some people need to be on medication long term. If the other factors (practical and psychological) are dealt with, patients can often come off their medication.

For the Christian, there is the added benefit of prayer. The Christian counselor can help determine if there is a need for repentance, as well as encourage patients to realize their value in God’s eyes. Although the Bible does not directly address depression, it contains much wisdom. We can be assured that God comforts us in our suffering (Ps 23; Isa 49:13, 51:3, 12; John 14:1; 2 Cor 1:3-5), and offers us peace (John 16:33) and rest (Matt 11:29, 30); we can take every thought captive (2 Cor 10:5), we can be angry but should not sin (Eph 4:26); we can know that others have suffered, including Christ (consider his agony in the Garden of Gethsemane, not to mention on the cross) and that suffering produces perseverance (Rom 5:3); we can give our anxiety to God (Phil 4:6; 1 Pet 5:7); and we can look to the day where there will be no more tears (Rev 21:4). Prayer counseling can help people know the comfort of the Father, the suffering and sacrifice of the Son, and the inspiration of the Holy Spirit. It is also important to recognize that although evil spirits are seldom the direct cause of depression, there is a good chance that they will seek to worsen it, by parasitically jumping on the bandwagon of negative thoughts, guilt and poor self-esteem. An experienced Christian counselor can discern the presence of evil spirits, deal with them through their authority in Christ, and teach the sufferer to listen to the truth of God, rather than the lies of the enemy.

I have tried to offer a simplified understanding and treatment approach for a complex condition! Obviously each aspect I have mentioned can be elaborated on at length; the important thing to remember is that there are many aspects to depression, and the more we are aware of these, the better we can minister to those who suffer.